I.V. Pershukov is a professor, Doctor of Medical Sciences, and head of the Department of Hospital Therapy with a course in Radiological Diagnostics and Oncology at Jalal-Abad State University.
- What is the role of statins in modern treatment? Is it possible to do without them?
- Previously, it was possible to manage without statins, but today their use has become necessary. These medications not only lower the level of harmful cholesterol (low-density lipoproteins) but also impact overall mortality and the incidence of cardiovascular diseases, especially in patients at high and very high risk. Statins, which belong to the class of HMG-CoA reductase inhibitors, play a key role in the prevention of atherosclerosis and its complications.
The history of statins began in the 1970s when Professor Akira Yamamoto in Japan used mevinolin to treat a girl with familial hypercholesterolemia.
Until 1994, the necessity of statins was not so obvious, but the situation changed with the results of the 4S study (Scandinavian Simvastatin Survival Study), conducted among 4,444 patients who had suffered a heart attack or had angina. This study first demonstrated the effectiveness of simvastatin in reducing the number of myocardial infarctions by 34%, mortality from coronary heart disease by 42%, and strokes by 28%, which became a strong argument in favor of using statins.
Since then, statin therapy has ceased to be viewed solely as a way to lower cholesterol; it has become an important part of atherosclerosis treatment.
Today, 32 years later, despite the emergence of new drugs such as ezetimibe and PCSK9 inhibitors, statins remain the most common and effective therapy for the prevention and treatment of atherosclerosis.
- If harmful cholesterol is high, its reduction is understandable. But why reduce it if it is normal?
- Cholesterol norms are developed for healthy individuals; however, laboratories cannot assess the individual risks of each patient. Determining and analyzing these values should be done by doctors.
Atheroma – an atherosclerotic plaque that hinders normal blood flow and causes diseases (coronary heart disease, ischemia)
In healthy individuals without risk factors, the likelihood of a heart attack or stroke is low. However, in patients with hypertension, these risks are significantly higher. Leaving such patients with high levels of harmful cholesterol is extremely undesirable, as it can lead to an increase in the number of heart attacks and strokes. To assess risks, doctors use special scales that help establish target cholesterol levels for each patient.
- What should be done if patients are taking statins but do not reach the target cholesterol level?
- This problem is widespread worldwide.
Studies have shown that complications of atherosclerosis occur more frequently in people who have not taken statins. Those who took statins but did not reach target levels had a lower frequency of complications, while the lowest frequency was observed in patients who maintained target cholesterol levels long-term.
In the past decade, expert opinions in Europe and the USA have diverged. The main differences between the recommendations are as follows:
- American ACC/AHA 2013 recommendations:
- The "fire and forget" approach, with no need to monitor lipid levels
- It is recommended to use only those doses of statins that have been studied in clinical trials, focusing on high doses to achieve a 50% reduction in LDL levels (atorvastatin 40-80 mg and rosuvastatin 20-40 mg)
- European ESC/EAS 2011 recommendations:
- Consideration of four risk categories and corresponding target LDL levels
- The importance of monitoring target cholesterol levels to evaluate therapy effectiveness.
My experience working for 10 years in a state clinic in the Russian Federation showed that among 24,000 patients who visited my office, 85-88% needed statin therapy, and among them, 70-80% reached target cholesterol levels.
- There is an opinion that statins are more harmful than beneficial. They can cause cancer, diabetes, and other serious diseases. Is this true?
- This is a myth. Trust in doctors in the countries of the former USSR is significantly lower than in Western countries.
A recent study published in the British Medical Journal (BMJ Open 2022;12:e061350. doi:10.1136/bmjopen-2022-061350) assessed the use of statins in 91 countries from 2015 to 2020.
The frequency of statin use by regions of the world in 2015-2020
The highest use of statins is observed in North America, followed by Europe, then Latin America and the Middle East, while the lowest is in East and South Asia and African countries.
Statistical data on statin use by countries in 2015-2020.
In summary:
- Statins do not cause cancer with long-term use. Some studies even show a reduction in the incidence of oncological diseases.
- Long-term use of statins does not lead to diabetes; numerous studies have found no such connection.
- Statins do not increase the incidence of liver cirrhosis with long-term use.
The frequency of serious complications from statin use is extremely low — rhabdomyolysis occurs less frequently than in 1 out of 1,000,000 patients taking atorvastatin or rosuvastatin at recommended dosages.
In my practice, there have been no recorded cases of persistent elevation of liver enzymes that did not resolve after adjusting the statin dosage. The only case of hepatitis was associated with a concurrent infection with the hepatitis B virus.
Thus, I strongly recommend statins for patients at risk of atherosclerosis and its manifestations (for example, chronic coronary heart disease, myocardial infarction, stroke). Their proper use is the key to the health of the nation.
